This questionnaire will be combined with information gathered during the consultation and used to build an individual nutritional programme specifically tailored to your needs and lifestyle. Please answer the questions as accurately as you can. All personal information provided is strictly confidential.

Please complete the form in one sitting only and then submit. If you are interrupted or inadvertently submitted your form before completion, you can open a new version and start where you left off. As long as the Client Booking Reference is completed correctly, we'll match them up!

Please fill in the number of times you eat the food referred to in the questions below.

Please complete the following 3-day food diary ensuring one of the days is over a weekend, and remember to include EVERYTHING! Don’t ignore mouthfuls or handfuls.  Please indicate portion size and provide information about the food source e.g. homemade, restaurant, shop bought etc.  Our nutritional therapy sessions are non-judgmental and designed to move you forward from where you are now so as to benefit your health.  Please do not be embarrassed to write down what you eat or drink.  The more accurate information you provide the more effectively we can tailor a realistic and achievable programme for you.

Some people find it helpful to print off the diary and jot down what they eat and drink during the day, then fill it in on screen or return in the post to the clinic (ideally at least 2 weeks before your consultation) or bring it with you on the day of your appointment.

This Agreement is between the IINH Student Nutritional Therapist (in training with the International Institute of Nutrition and Health), working under the supervision of a qualified Nutritional Therapist, and the Client. Nutritional Therapy support will focus on goals agreed during an initial discovery call and developed throughout the clinic process.  

About Nutritional Therapy:
Nutritional Therapy is a client-centre approach that applies nutrition and lifestyle science to support health, wellbeing, and performance. Practitioners assess potential nutritional imbalances and provide personalised nutrition and lifestyle recommendations. Nutritional Therapy is a complementary approach and is not a substitute for medical care. Practitioners do not diagnose medical or mental health conditions and will refer clients to appropriate healthcare professionals where necessary.  

Therapist–Client Relationship:

The Nutritional Therapist agrees to uphold the ethics and standards set out by IINH, set out in the IINH Code of Ethics
The Client remains fully responsible for their own health decisions, actions, and outcomes.
Nutritional Therapy may touch on multiple areas of life, and the Client alone is responsible for how recommendations are applied.
Individual results may vary, and recommendations are specific to the Client and not suitable for others.
Nutritional Therapy does not replace medical, psychological, legal, or other professional care. Clients are responsible for seeking such care when required.
The Client agrees to communicate honestly, engage fully, and provide accurate information regarding medical history, diagnoses, medications, and supplements.
It is imperative the Client contacts their Nutritional Therapist if unclear about any aspect of the programme. The Nutritional Therapist will provide clarification on any issues. The Client is advised to report any concerns about nutritional therapy promptly to your Nutritional Therapist for discussion and action. 
The Client must contact your Nutritional Therapist should you wish to continue any specified supplement programme for longer than the agreed period, to avoid any potential adverse reactions.

Confidentiality:
All information shared within the Nutritional Therapist–Client relationship is treated as confidential in line with the IINH Code of Ethics. This relationship is not legally privileged. Information may only be disclosed with written consent, where required by law, or where there is a reasonable belief of risk of harm, illegal activity, or public safety concerns.

 

Training & Use of Information:
The Nutritional Therapist is completing supervised training toward an IINH-accredited Diploma. Client information may be shared with the Clinic Coordinator and Supervisor. Case information may be discussed anonymously for training, supervision, and professional development purposes.

 

Cancellations:
Clients are responsible for providing at least 24 hours’ notice for cancellations or postponements. Missed appointments may be charged, with reasonable efforts made to reschedule.

 

Record Retention:
Client records will be retained securely in digital format for a minimum of eight (8) years.

 

Termination:
Either party may terminate this Agreement at any time